Screening instruments for cognitive impairment in older patients in the Emergency Department: a systematic review and meta-analysis

Abstract

Background cognitive impairment is highly prevalent among older patients attending the Emergency Department (ED) and is associated with adverse outcomes. Methods we conducted a systematic review and meta-analysis to evaluate the diagnostic accuracy of cognitive screening instruments to rule out cognitive impairment in older patients in the ED. A comprehensive literature search was performed in MEDLINE, EMBASE, CINAHL and CENTRAL. A risk of bias assessment using QUADAS-2 was performed. Results 23 articles, examining 18 different index tests were included. Only seven index tests could be included in the meta-analysis. For ruling out cognitive impairment irrespective of aetiology, Ottawa 3 Day Year (O3DY) (pooled sensitivity 0.90; (95% CI) 0.71–0.97) had the highest sensitivity. Fourteen articles focused on screening for cognitive impairment specifically caused by delirium. For ruling out delirium, the 4 A’s Test (4AT) showed highest sensitivity (pooled sensitivity 0.87, 95% confidence interval (95% CI) 0.74–0.94). Conclusions high clinical and methodological heterogeneity was found between included studies. Therefore, it is a challenge to recommend one diagnostic test for use as a screening instrument for cognitive impairment in the ED. The 4AT and O3DY seem most promising for ruling out cognitive impairment in older patients attending the ED. The review protocol was registered in PROSPERO (CRD42018082509).

“Emergency Room Evaluation and Recommendations” (ER2) Tool for the Screening of Older Emergency Department Visitors With Major Neurocognitive Disorders: Results From the ER2 Database

“…Only about half of individuals who meet the criteria for major neurocognitive disorders are diagnosed by a clinician ( 1 , 11 ). Furthermore, the diagnosis of major neurocognitive disorders is often delayed, with more older patients diagnosed at advanced stages of neurocognitive disorders, rather than at their onset ( 4 , 9 ). As such, temporal disorientation is frequently observed in this population.…”

“…The inability to give month and/or year is the only ER 2 item which explores cognition. Temporal disorientation is frequently affected at advanced stages of neurocognitive disorders and, thus, this item could be used to screen individuals with undiagnosed major neurocognitive disorders, regardless of their etiology (3,4,9,11). Since 2017, ER 2 has been included in the electronic medical record of ED patients at the Jewish General Hospital (JGH, Montreal, Quebec, Canada) as part of clinical quality improvement program.…”

“…Therefore, screening for major neurocognitive disorders should systematically be included as a step in assessing older patients upon arrival to the ED. There are obstacles to implementing systematic screenings of major neurocognitive disorders in EDs ( 9 , 10 ). First, EDs are under duress because of overcrowding, delays, and diversions, which have increased to epidemic proportions ( 6 ).…”

Impaired Executive Function and Depression as Independent Risk Factors for Reported Delirium Symptoms: An Observational Cohort Study Over 8 Years

“…Impaired executive function and depression increase the risk of delirium symptoms over the long term. Screening for these factors can be helpful to identify high-risk patients, particularly before an elective medical procedure, even in relatively healthy subjects ( Tieges et al, 2020 ; Calf et al, 2021 ). Short neuropsychological assessments like the GDS or TMT-B could be an approach to identify subjects at risk.…”

“…Screening for risk factors based on differentiated information on specific cognitive domains can help take precautions to prevent delirium and POCD ( Tieges et al, 2020 ; Calf et al, 2021 ). More specific and efficient tasks can be chosen for pre-intervention assessments as they take less time.…”